Before beginning today’s Note, an acknowledgement of the start of Black History Month. Black history is very much American history. To observe Black History Month, then, is to reflect on where we came from, how we arrived at our present moment, and where we might be going next. Reflecting on this moment, I am both inspired and provoked by the words of James Baldwin, who said during a similarly uncertain period in the life of this country, “American history is longer, larger, more various, more beautiful, and more terrible than anything anyone has ever said about it.”
On to today’s note. Public health aims to create the social, economic, and cultural conditions that make people healthy. I have commented often here that such an effort entails work in areas that are traditionally not considered in the remit of health, including education, housing, and fighting racial and gender inequity. These issues are all deep and profound challenges in and of themselves, defying easy solutions. One additional stumbling block in the way of solving these problems is that they are liable to be treated as separate concerns, with separate solutions. When we view these foundational drivers of health and well-being through a narrow lens, it can create fragmentation. If those who are interested in shaping better social, economic, and cultural structures choose to address only their remit, it dilutes energy, diffuses what we do, and potentially even puts us at odds with each other. Much can be learned from the past political season, where fragmentation of effort has been attributed, in part, to the ultimate outcome. One key lesson is that advancing change clearly means finding a way to bring together groups, while also respecting what makes them, and their concerns, unique. In a prior Dean’s Note, I introduced the concept of economic justice as a core motivation for public health. Today, a note on how we might couple this approach with a shared justice focus, to help us bridge the divides that can stymie efforts to create a healthier society.
The conditions that undermine the health of populations are often the result of an underlying injustice, frequently economic. Public health has, for this reason, long been shaped by its engagement with promoting justice. Defining, and promoting, justice informs the aims of moral philosophy (i.e. ethics). This philosophy is in turn rooted in the thinking of Aristotle, who, more than 2,000 years ago, defined justice as the notion that “equals should be treated equally and unequals unequally.” This is to say, if two people are thriving equally well, neither need receive any more or any fewer social resources than the other. But if one person is falling behind, justice demands that this person receive more, according to her need. In public health, we have historically applied this framework, in keeping with our aspirations, to reducing a range of inequities, mobilizing the universal drive for justice toward the narrowing of health gaps. Tackling the foundational causes of these problems, then, means working for justice. “Justice” is, of course, a broad concept; there are many ways that justice can be applied to the business of shaping social conditions. I would like to suggest here the utility of a shared justice approach—of our potential to unite a range of constituencies by speaking to a common human need for justice, dignity, and health.
Throughout history, we have seen the power of a shared-justice focus to ignite, and unite, social movements. Politicians have frequently used a call for justice to mobilize electoral coalitions and to galvanize support for ambitious agendas. This was the case in 1964, when President Lyndon B. Johnson declared “unconditional war on poverty in America” in his State of the Union address, when he spoke of his vision for “a world of peace and justice, and freedom and abundance, for our time and for all time to come.” In his speech, Johnson took care to frame the War on Poverty as an initiative designed to uplift all social groups, mitigating poverty “wherever it exists—in city slums and small towns, in sharecropper shacks or in migrant worker camps, on Indian Reservations, among whites as well as Negroes, among the young as well as the aged, in the boom towns and in the depressed areas.” Through a host of legislation, Johnson was able, in many respects, to make good on his promise to improve conditions for all Americans, through initiatives like the Economic Opportunity Act of 1964, The Food Stamp Act of 1964, and the Elementary and Secondary Education Act. The role of these programs as a means of creating a more just society was well expressed by Sargent Shriver, who Johnson selected to lead the initiative:
“[I]f the War on Poverty means anything, it is a statement that we must look, not just to the poor—but to the whole cloth too—and even to the loom. The whole fabric of our society must be rewoven, and the patterns we must weave are patterns of justice, opportunity, dignity, and mutual respect.”
Ultimately, the initially popular War on Poverty, and LBJ’s larger, overarching project of building a Great Society, would spark a backlash, helping to catalyze the Reagan era of “limited government,” and the trend of federal deregulation that continues to this day, and may accelerate under the Trump administration. Even so, many of the programs that were passed as part of the War on Poverty—including Medicare, Medicaid, and Head Start—remain ongoing, a testament to the durability of LBJ’s call for justice.
How might a call for shared justice be used to unite coalitions at the grassroots level? Jamelle Bouie recently suggested how such a mobilization might be achieved, using Jesse Jackson’s two presidential campaigns in the 1980s as models. Jackson was an outsider candidate, whose success depended on his ability to build coalitions and to speak to a broad range of interests, from economically pressured farmers, to women seeking pay equity, to minority populations fighting for civil rights, to LGBT Americans facing discrimination. By linking the shared justice of their appeals, Jackson was able to address the interests of these groups while also speaking to a larger theme, crafting a message that, while unable to win him the nomination, still resonates. In his speech at the 1988 Democratic Convention, Jackson articulated this message, likening disparate and marginalized groups to the patches of a quilt. Individually, Jackson argued, none could create much warmth, but, knitted together, they became “a thing of beauty and power and culture.” This metaphor, recalling Sargent Shriver’s “loom,” represents the demographics of Jackson’s Rainbow Coalition, which was formed to promote social justice and equal rights, uplifting all Americans—particularly those who felt excluded from the prevailing “Reaganomics” of that era. By speaking to the need for justice and dignity that underlies a range of pressing political concerns, Jackson avoided the danger of “missing the forest for the trees,” providing, I think, a clarifying example for our own efforts.
Public health is uniquely suited to communicate the link between justice and health. We know that when injustice is allowed to flourish, it undermines the structures that create health; the social, economic, and environmental conditions that determine the well-being of populations. Because health is a universal aspiration, our message may claim a universal appeal. There is power in this appeal; with this power comes responsibility. We need to make sure that the link between justice and health is more widely understood. We live in a country where epidemiological crises are frequently ascribed to infectious disease or unwise life decisions. It is up to us to “connect the dots” between, for example, the observation that black children are more likely to suffer from asthma than white children due in part to a legacy of housing discrimination. By making the implicit connection between health and injustice explicit, we take a step toward making the acceptable unacceptable, helping the global conversation evolve toward a more complete understanding of what makes people sick and what allows them to remain healthy.
The degree to which justice—both shared justice and economic justice—informs how we structure our society is also, more often than not, the degree to which members of that society can expect to live full, productive lives, free from the burden of disease. The clearer we can make this, the more we can bring about focus in pursuit of healthier populations at this divided political moment. This means that those who wish to be well must work—regardless of age, sex, occupation, or political party—to make such a world a reality. To mobilize all those who wish to be well—a potentially vast coalition—in pursuit of a healthier, more just world is an electrifying prospect, and one that is worth working toward, collectively, in the months and years ahead.
I hope everyone has a terrific week. Until next week.
Sandro Galea, MD, DrPH
Dean and Robert A. Knox Professor, Boston University School of Public Health
Acknowledgement: I am grateful to Eric DelGizzo for his contribution to this Dean’s Note.
Previous Dean’s Notes are archived at: http://www.bu.edu/sph/tag/deans-note/